Provider Demographics
NPI:1477648871
Name:BOUTROS, PETER R (LMHC, CASAC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:LMHC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DELMAR AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2875
Mailing Address - Country:US
Mailing Address - Phone:718-701-4736
Mailing Address - Fax:
Practice Address - Street 1:40 DELMAR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2875
Practice Address - Country:US
Practice Address - Phone:917-209-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
NY003124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)